Ulcerative colitis

Disease Description (Causes and Symptoms)

• Definition summary: Ulcerative colitis is a chronic inflammatory bowel disease confined to the mucosal layer of the colon (large intestine). It is characterized by lesions that begin in the rectum and spread continuously upward. Mucosal congestion, edema, ulcers, and pseudopolyps may occur.
• Causes (summary): The exact cause is unknown. Genetic susceptibility, immunological abnormalities of the intestinal mucosa, microorganisms (intestinal bacteria), and environmental factors (diet, stress, etc.) are thought to be involved in combination.
• Key pathophysiology: Chronic inflammation of the mucosal layer causes mucosal damage and ulcer formation → reduced intestinal absorption (diarrhea), bleeding (bloody stools), and increased mucus secretion. Systemic and extraintestinal symptoms (arthritis, spondylitis, biliary tract disease, etc.) may also occur.
• Main symptoms: Diarrhea containing blood and mucus (which can cause anemia and dehydration), abdominal pain (mainly associated with bowel movements), frequent bowel movements/urgency/fecal incontinence, fever, and weight loss. Constipation-like symptoms may occur when lesions are limited to the rectum.
• Clinical types: Chronic relapsing (most common), chronic continuous (lasting for several months), acute fulminant (severe systemic symptoms and risk of emergency).

Treatment (Standard Treatment · Precautions · Risk of Complications · Self-Management)

• Treatment goals: Induce remission during acute exacerbations, prevent relapse (maintenance), achieve mucosal healing, prevent complications (perforation, severe bleeding, toxic megacolon), and manage colorectal cancer risk.
• Drug treatment (stepwise approach)
  • 5-ASA agents (sulfasalazine, mesalazine): Induction and maintenance therapy for mild to moderate disease. Suppository or enema formulations are used for rectal lesions. Side effects: gastrointestinal symptoms, headache, and rarely liver or blood abnormalities.
  • Corticosteroids (oral or intravenous; e.g., prednisone, methylprednisolone): Short-term induction therapy for moderate to severe disease. Long-term use can cause serious side effects (osteoporosis, hypertension, diabetes, infection, etc.) → tapering and discontinuation are recommended.
  • Immunomodulators (azathioprine, 6-MP, etc.): Maintenance therapy for patients who are steroid-dependent or steroid-refractory. Monitoring for blood toxicity (bone marrow suppression) is necessary (regular blood tests); TPMT testing may be considered.
  • Biologics and small molecules
    • Anti-TNF agents (e.g., infliximab), anti-α4β7 agents (vedolizumab), anti-IL12/23 agents (ustekinumab), etc.: Used for severe or drug-refractory disease. Increased risk of infection (tuberculosis and opportunistic infections) — tuberculosis and HBV testing are required before use.
    • JAK inhibitors (e.g., tofacitinib): May be used for moderate to severe disease (the indication and risks must be confirmed).
  • Antibiotics (metronidazole, ciprofloxacin, etc.): Used for infectious complications or as adjunctive treatment.
• Surgical treatment
  • Indications: Failure to respond to drug treatment, toxic megacolon, intestinal perforation or persistent bleeding, dysplasia or cancer, etc.
  • Standard surgery: Total colectomy and proctectomy (radical resection). After creating an ileal pouch, preservation of the anal sphincter through an ileal pouch-anal anastomosis (IPAA) is attempted to preserve bowel function.
  • After surgery: Increased bowel movement frequency and temporary fecal incontinence may occur initially, but most patients adapt.
• Monitoring and prevention
  • Before/during diagnosis and treatment: Colonoscopy (with biopsy), blood tests (CBC, CRP), and stool tests (to rule out intestinal infection and test calprotectin) are necessary.
  • Before using biologics, tuberculosis testing (TB) and hepatitis B testing are needed, and keeping vaccinations up to date (e.g., influenza, pneumococcal, HPV, etc.) is recommended.
  • Cancer surveillance: Regular colonoscopy according to the extent and duration of the lesions (in general, surveillance for extensive colitis begins 8–10 years after symptom onset, followed by examinations every 1–3 years depending on risk).
• Lifestyle management and precautions
  • Diet: Avoid foods that trigger symptoms individually (overeating, spicy foods, high-fat foods, caffeine, etc.) and maintain fluid intake. Specific dietary approaches may help relieve symptoms, but there is no standardized diet.
  • Medication and behavior precautions: NSAIDs should be used with caution because they may worsen symptoms. Smoking has been reported to have a protective effect against ulcerative colitis (but is not recommended); because of its substantial systemic harm, smoking cessation is recommended.
  • Warning signs of complications: Immediate emergency evaluation is necessary in the event of high fever, severe abdominal pain, persistent bleeding, or sudden abdominal distension (suspected toxic megacolon).
• Prognosis: A chronic course with repeated relapses and remissions is common. If extensive lesions persist for a long time, the risk of colorectal cancer increases (regular surveillance is necessary).

Checklist Before an Outpatient Visit (Including Example Questions)

• Items and information to prepare
  • A list of currently used medications (including prescription drugs, nonprescription drugs, and supplements)
  • History of previous surgery and allergies (medications, latex, etc.)
  • Copies or summaries of recent test results (colonoscopy findings/biopsy, blood test results, imaging tests)
  • Bowel movement diary (past 1–2 weeks): number of bowel movements per day, stool characteristics (including mucus and blood), and whether pain is present
  • Records of systemic symptoms such as weight changes, fever, joint pain, and skin symptoms
  • Smoking, alcohol use, possibility of pregnancy, and vaccination history
• Examples of materials and questions to show the doctor during the visit (self-check before the appointment)
  • How many bowel movements have there been in the past 24 hours, and is there blood in the stool?
  • What are the recent changes in weight (kg) and food intake?
  • What medications are currently being taken (dose and time of administration)?
  • Are the results of recent tests (colonoscopy, blood tests) available?

Examples of General Questions to Ask the Doctor

• What is the purpose of this medication (the prescribed medication), and what effects are expected? What side effects may occur, and how should they be managed if they occur?
• What is the current severity of my disease, and what are the treatment goals (symptom relief versus mucosal healing)?
• How often should I undergo testing (CBC, liver function tests, colonoscopy, calprotectin, etc.)?
• When using biologics or immunosuppressants, how should tuberculosis and hepatitis testing and vaccinations be managed?
• What are the recommendations regarding treatment during pregnancy and breastfeeding and plans for childbirth?

Examples of Disease-Specific Questions

• In my case, based on the colonoscopy and biopsy findings, how far does the inflammation extend (only the rectum, the left side, or the entire colon)? How do the cancer surveillance interval and treatment strategy (topical treatment versus systemic treatment) differ accordingly?
• I use steroids frequently (or am steroid-dependent). What maintenance therapy (immunomodulators, biologics, etc.) do you recommend to help discontinue steroids? What are the expected benefits and risks?

(Note: This information is general medical information. Diagnosis and treatment should be decided according to the individual condition in consultation with the treating physician.)